Despite the effectiveness of brief lifestyle interventions delivered in primary health care (PHC), implementation in routine practice remains suboptimal. Previous research suggests that there are many barriers to PHC clinicians addressing lifestyle risk factors, however few studies have identified the importance of various factors and how they shape practices. This thesis aimed to develop and describe a theoretical model to explain the lifestyle risk factor management practices of PHC clinicians and to identify critical leverage points for intervention. The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in NSW, Australia, involving 48 PHC providers working outside of general practice. Grounded theory principles were used to inductively develop a model, involving three main stages of analysis: 1) an initial model was developed based on quantitative analysis of clinician survey and audit data, and qualitative analysis of a purposeful sample of participant interviews (n=18) and journal notes; 2) the model was then refined through additional qualitative analysis of participant interviews (n=30) and journal notes; and 3) the usefulness of the model was examined through a mixed methods and case study analysis. The model suggests that implementation of lifestyle risk factor management reflects clinicians??? beliefs about commitment and capacity. Commitment represents the priority placed on risk factor management and reflects beliefs about role congruence, client receptiveness and the likely impact of intervening. Capacity beliefs reflect clinician views about self efficacy, role support and the fit between risk factor management and ways of working. The model suggests that clinicians formulate different intervention expectations based on these beliefs and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians??? appraisal of the overall benefits and costs of addressing lifestyle issues acts to positively reinforce or to diminish their commitment to implementing these practices. The model extends previous research by outlining a process by which clinicians??? perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

Globally, the prevalence of diabetes has seen a significant increase, rising from 211 million in 1990 (3.96% of the global population at that time) to 476 million in 2017 (6.31% of the global population in 2017). Extensive research has been conducted to study the causes of diabetes from a data-driven approach, leading to the development of prospective models for predicting future diabetes risks. These studies have highlighted the strong correlation between diabetes and various biomarker factors, such as BMI, age, and certain blood test measures. However, there is a lack of research that focuses on building prospective models to predict future diabetes risks based on lifestyle factors. Therefore, this thesis aims to employ popular machine learning methods to investigate whether it is possible to predict future diabetes using prospective models that incorporate self-controllable lifestyle factors. Our analysis produced remarkable results, with the biomarker model achieving an average validation AUC score of 0.78, while the lifestyle model reached 0.70. Notably, lifestyle features demonstrate a greater predictive capacity for short-term new-onset diabetes when compared to the long-term endpoint. The biomarker model identified visceral fat as the most significant risk factor, whereas income level and employment emerged as the top risk factors in the lifestyle model. This thesis represents an innovative approach to diabetes prediction by leveraging lifestyle factors, providing valuable data-driven insights into the root causes of diabetes. It addresses a critical research gap by highlighting the significant role of lifestyle factors in predicting the future onset of diabetes, particularly within the context of parametric modeling. / Thesis / Master of Science (MSc)

People with psoriasis are known to engage in high levels of unhealthy lifestyle behaviours which may lead to poorer psoriasis outcomes and increase the risk of cardiovascular disease (CVD). Thus, helping individuals with psoriasis understand the link between behaviours and health risks, that is health risk communication, and direct support for lifestyle behaviour change (LBC) are important aspects in optimal management of psoriasis, a long-term inflammatory skin condition. There are two aspects of the literature that remain unclear. First, whether adequate support is given to patients to enable them to understand the links between lifestyle behaviours and health outcomes is part of psoriasis patient management strategies. Second, whether there is agreement around effective health risk communication techniques. This programme of research aimed to examine these gaps in the literature using four related studies. The first study used content analysis to examine general and dermatology-specific healthcare professionals’ core training competencies for evidence of skills relating to LBC. An important finding was the lack of explicit skills relating to LBC and changing understanding of health risks. There was little or no reference to recognised LBC techniques that could be used to support and facilitate LBC with patients. The second study used observational techniques to examine messages about the links between behaviour and health outcomes and LBC signposting (such as leaflets or posters about healthy living) for patients with psoriasis in primary and secondary care patient waiting areas. There was little evidence of psoriasis-specific information about healthy living. Generic information (not specifically about psoriasis) was often of poor quality and was poorly displayed, and did not conform to evidence-based recommendations for effective LBC signposting. The third study combined observational and qualitative techniques to examine how healthcare professionals communicate information about CVD risk to patients and the role of LBC in reducing risk in the context of primary care risk assessments with people with psoriasis. A key finding was that interpretation of risk information was not always linked to specific advice about how to modify each risk factor. Discussion was mostly instructional rather than a shared collaborative discussion about behaviour change and risk reductionThe fourth study used experimental methods to examine the effects of message framing theory as a health risk communication strategy on reported behavioural intentions (BIs) in people with psoriasis. An important finding was that for messages about psoriasis symptom reduction, gain-framed (positively-framed) messages were more effective in increasing BIs for alcohol reduction. Conversely, for messages about CVD risk reduction, loss-framed (negatively-framed) messages were more effective for increasing BIs to reduce alcohol consumption. The body of work presented in this thesis demonstrated that much needs to be done to increase the skill sets of healthcare professionals in order to help people with psoriasis recognise the specific links between their own health behaviours and health outcomes. In addition specific recommendations have been suggested as a way of improving risk communication strategies, such as using theory-based personally-relevant health information for people with psoriasis.

The present study aims to explore the role of self-control, morality and lifestyle risk (core elements of Situational Action Theory-SAT) on adolescent victimization. Although previous studies produced plenty of support to the influence of self-control and lifestyle risk on victimization, no study so far measured level of morality as predictor of victimization. The study focuses especially on exploring the effect of morality in causation of victimization among adolescent. Analyses are based on data collected for Malmö Individual and Neighbourhood Development Study (MINDS) during 2011-12, when adolescents attained at the age between 16 and 17. Pearson’s correlation and binary logistic regression are run to examine relation and the magnitude of effect of each predictor. Strong relation of adolescent victimization with lifestyle risk and self-control is revealed in this study, that awarded strong support to the existing studies. A correlation between morality and victimization among adolescent also identified. Overall findings step-ahead the possibilities of application of the core elements (morality, self-control and lifestyle risk) of SAT in explanation of victimization. Gender remains as a strong predictor of adolescent victimization, where significant gender differences in level of morality is identified.

Crime comes in many different forms and can be viewed differently depending on culture, individual factors and geography. This increases the importance of discussing the subject by continually analyzing its causes, to eventually enable the development of methods and means to stop it. This study seeks to contribute to this process by analyzing factors that influence crime but also the ending of it, in the context of social factors. Accordingly, the overall goal of the study is to contribute to broadening the know-how about what influences criminal careers to help in the development of methods to stop them. This is done by analyzing the field from in two approaches; (1) what indicate crimes and (2) what contributes to the ending. This is of great importance today as it will fill a prevailing shortage in previous research which tend to focus on the field in one of the two approaches and often with the same type of participants. To achieve its purpose, the study includes individuals which are young with on-going criminal lifestyles and older which have put their criminal past behind them. Through the study analysis six themes where identified; threat of punishment, drug abuse, family relations, environmental aspects and school. / Brott förekommer i många olika former och betraktas skiftande beroende på kultur, individuella och geografiska faktorer. Brottslighet är dessutom ett eskalerande samhällsproblem som har med sig stora negativa konsekvenser på ekonomisk aktivitet och den psykiska hälsan hos samhällsinvånare. Detta sätter stor vikt på att kontinuerligt diskutera ämnet och analysera orsaker till kriminalitet för att vidareutveckla förebyggande metoder och processer. Denna studie bidrar till denna process genom att analysera faktorer som indikerar brott men också varför respondenter valt att avsluta sina kriminella karriärer, i samband med sociala band teorin. Följaktligen, är det övergripande målet att bidra till att bredda kunskapen om vad som påverkar kriminella karriärer och därav bidra till utvecklingen av metoder för att stoppa dem. Detta utförs genom att analysera studieområdet ur två olika infallsvinklar; (1) vad som skapar brott och (2) vad som stoppar det. Detta ger inte enbart studien samhällsviktig tyngd utan bidrar också till en bristfällig forskning som tenderar att endast fokusera på en infallsvinkel och ofta i datainsamling från samma typ av deltagare. För att uppnå sitt syfte har studien inkluderat individer med pågående kriminell livsstil samt personer vars kriminella karriär ligger bakom dom. Sex teman identifierades under studieanalysen; straffhot, drogmissbruk, familjerelationer, miljöaspekter och skola.

Rising worldwide rates of noncommunicable diseases (NCDs) in the Middle East, principally Saudi Arabia, have put an increasing load on the health system and employers. Middle Eastern organizations have been slow to develop targeted health programs, which include an emphasis on employee productivity. The purpose of this study was to determine the relationship, if any, between employee lifestyle and workplace productivity. Productivity is the amount of work produced based on the time and cost required to do so. The underlying theoretical foundations of this research were the socioecological health model and the human capital model. The quantitative, ex post facto design relied on secondary data from Saudi Aramco. Lifestyle data were collected from a health risk assessment including the Stanford Presenteeism Scale. Data analysis consisted of both a correlational and multiple regression analysis. Correlational results indicated that exercise, tobacco use, body mass index (BMI), and nutrition were significantly related to workplace productivity. Exercise and nutrition had a significant positive correlation with workplace productivity, while tobacco use and increasing BMI were negatively correlated with workplace productivity. Multiple regression analysis results explained 21% of the variance in the dependent variable, a sizable percentage with such a large sample. Overall, these results suggest a strong influence of health choices on productivity. Since this research was the first to explore the unique cultural context and draw attention to the increasing NCD burden, the results are notable. Implications of this research should resonate with organizational leaders in the Middle East, and provide a clear opportunity to improve organization and human performance.

BACKGROUND: Pregnancy-induced hypertension (PIH) and gestational diabetes mellitus (GDM) are among the leading causes of disability and death for women and their babies. Identifying risk factors for these pregnancy-related complications is essential to their prevention. Studies identifying preventive models for PIH and GDM are few. OBJECTIVES: This study was designed to evaluate lifestyle and personal predictors of PIH and GDM in a cohort of nearly 20,000 pregnant women. METHODS: The exposure data for the study were derived from a combination of a telephone interview and a questionnaire completed approximately 2 months after conception during the period from 1984 to 1987. The initial questionnaires asked for information on three periods: 3 months before conception, at conception, and 2 months after conception. Subjects included 19,312 women, aged 18-<45 years, who did not have excessive intakes of alcohol or food, were neither underweight (BMI >18.5) nor extremely overweight (BMI <40), and did not use illegal drugs during the first trimester of pregnancy. Outcome data on the mother and baby were collected approximately one year after the expected data of delivery. Logistic regression models were used to estimate the odds ratios (OR), and 95% confidence intervals (CI), as well as receiver operating characteristic (ROC) curves predicting PIH and GDM. Akaike Information Criteria (AIC) were used to select the best predictors of these two outcomes. Factors found not to affect PIH or GDM (based on a two-unit decrease in the AIC) were excluded from the final models. RESULTS: Based on the outcome data collected, there were 204 PIH cases, 358 GDM cases, and 538 who had PIH and/or GDM. After selecting the outcome predictors using AIC values, we identified three predictive models—one each for PIH, GDM, and either PIH or GDM. Factors found to predict PIH included age, previous hypertension or type 1 or 2 diabetes, pre-pregnancy BMI, parity, exercise, red meat consumption, margarine consumption, cigarette smoking, and weight change at 2 months. The final AIC value for PIH was 2084.12 and the AUC value was 0.76. GDM was predicted by age, previous GDM (in an earlier pregnancy), pre-pregnant BMI, height, exercise, race, dairy consumption, and cigarette smoking, with an AIC value of 3288.74 and an AUC value of 0.70. The combined model (predicting either PIH or GDM) was best predicted by age, history of GDM in a previous pregnancy, pre-pregnant BMI, previous history of hypertension, height, exercise, dairy consumption, red meat consumption, parity numbers, cigarette smoking, and weight change at 2 months with an AIC value of 3288.74 and an AUC value of 0.71. CONCLUSIONS: In these analyses, separate models predicting PIH and GDM were better than a combined model predicting PIH or GDM. These final models indicate that we can reasonably identify women who are at increased risk for adverse maternal outcomes associated with hypertensive disorders or diabetes during pregnancy.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22036号 / 医博第4521号 / 新制||医||1038(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 滝田 順子, 教授 松田 道行, 教授 山田 亮 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The thesis provides a comprehensive overview of key issues affecting practice, policy and patients, in current efforts for colorectal cancer (CRC) disease control. The global burden of CRC is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030. CRC incidence and mortality rates vary up to 10-fold worldwide, which is thought to reflect variation in lifestyles, especially diet. Better primary prevention, and more effective early detection, in screening and surveillance, are needed to reduce the number of patients with CRC in future1. The risk factors for CRC development include genetic, behavioural, environmental and socio-economic factors. Changes to surveillance, which offer non-invasive testing and provide primary prevention interventions represent promising opportunities to improve outcomes and personalise care in those at risk of CRC. By systematic review of the literature, I highlight the gaps in comparative effectiveness analyses of post-polypectomy surveillance. Using micro-simulation methods I assess the role of non-invasive, faecal immunochemical testing in surveillance programmes, to optimise post-polypectomy surveillance programmes, and in an accompanying sub-study, I explore the value of adding an adjunct diet and lifestyle intervention. The acceptability of such revisions is exposed to patient preference evaluation by discrete choice experiment methods. These preferences are accompanied by evidence generated from the prospective evaluation of the health literacy, numeracy, sedentary behaviour levels, body mass index (BMI) and information provision about cancer risk factors, to highlight the potential opportunities for personalisation and optimisation of surveillance. Additional analysis examines the optimisation of a screening programme facing colonoscopy constraints, highlighting the attendant potential to reduce costs and save lives within current capacity.

Introduction: Les personnes vivant avec le VIH (PVVIH) présentent des risques accrus d’ostéoporose et de lipodystrophie. Peu d’études se sont penchées sur l’association entre les déterminants du style de vie, le risque d’ostéoporose et le risque de lipodystrophie chez les PVVIH. Objectifs: L’objectif primaire était d’évaluer l’association entre l’ostéoporose, la lipodystrophie ainsi que différents déterminants du style de vie chez les PVVIH. Méthodologie: Tous les participants de la Cohorte canadienne VIH et vieillissement (CCVV) avec des données sur la densité minérale osseuse (DMO), mesurée par absortiométrie biphotonique à rayons X (DXA), ont été inclus dans cette étude transversale. Les déterminants du style de vie d’intérêt étaient : le revenu annuel, le niveau d’éducation, l’exercice physique ainsi que les consommations d’alcool, de tabac et de drogues illicites. Les covariables mesurées incluaient l’historique complet de la médication antirétrovirale, les comorbidités, les co-infections, la charge virale, le compte de CD4+ au recrutement et le compte de CD4+ nadir. L’ostéoporose a été définie par un score T de -2.5 ou moins. La lipodystrophie, évaluée par la composition corporelle via DXA, a été définie par un fat mass ratio (rapport des pourcentages de gras entre le tronc et les membres inférieurs) supérieur à 1.33 pour les femmes et 1.96 pour les hommes. Les rapports des cotes et les intervalles de confiance à 95% (IC95%) au recrutement ont été estimés en utilisant des régressions logistiques multivariées. Résultats: Nous avons inclus 547 PVVIH (âge médian 55 ans, 88% d’hommes) et 97 contrôles séronégatifs au VIH (âge médian 54 ans, 54% d’hommes). L’ostéoporose était présente chez 13% des PVVIH et 6% des contrôles (OR 2.21, IC 95% [0.96 – 6.06]). La lipodystrophie était présente chez 138 (28.3%, IC 95% 24.3 – 32.3%) des 487 PVVIH avec des données sur la disposition du gras corporel. Aucun des déterminants du style de vie était associé à l’ostéoporose ou à la lipodystrophie. Par contre, les covariables associées à un risque accru d’ostéoporose étaient l’âge avancé, un indice de masse corporelle (IMC) réduit et la co-infection à l’hépatite C. Les covariables associées au risque accru de lipodystrophie étaient l’âge avancé, l’hypertension, l’exposition prolongée aux antirétroviraux, ainsi que les expositions prolongées aux inhibiteurs nucléosidiques de la transcriptase inverse (INTI) et aux inhibiteurs de l’intégrase (INI). Conclusion: Aucune association n’a été décelée entre les déterminants du style de vie étudiés et l’ostéoporose ou la lipodystrophie. / Background: As a consequence of ART, people living with HIV (PLWH) are at higher risk for osteoporosis and lipodystrophy. However, the risk may also be influenced by lifestyle factors, but few studies have explored the association between modifiable lifestyle factors and the risk of osteoporosis or lipodystrophy in the PLWH population. Objectives: Our primary objective was to evaluate the lifestyle factors in relation to the risks of osteoporosis and lipodystrophy in a PLWH-based cohort. Methods: We conducted a cross-sectional analysis of data from the Canadian HIV and Aging Cohort Study (CHACS). We included all participants with available bone mineral density T-scores, which were measured by dual-energy X-ray absorptiometry (DXA) scans. Lifestyle risk factors of interest included annual income, education level, alcohol intake, tobacco use, illicit drug use and physical exercise. Other covariates considered were full antiretroviral medication history, medical comorbidities, coinfections, viral load, nadir CD4+ and current CD4+ count. Osteoporosis was defined by a T-score of -2.5 or lower at any of the measured sites. Lipodystrophy was assessed on whole body DXA and defined as a fat mass ratio (the ratio between trunk and lower limbs fat mass) greater than 1.33 for women and 1.96 for men. Baseline prevalence odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by multivariate logistic regressions. Results: We included 547 PLWH (median age 55 years, 88% males) and 97 HIV-uninfected controls (median age 57 years, 64% males). Osteoporosis was present in 13.0% of PLWH (95% CI 10.2 – 15.8%) and 6% of controls (95% CI 1.4 – 11.0%); the OR of osteoporosis for HIV seropositivity was 2.21 (95% CI [0.96 – 6.06]). Lipodystrophy was found in 138 (28.3%, 95% CI 24.3 – 32.3%) of the 487 PLWH for which a fat mass ratio (FMR) was available. None of the lifestyle factors of interest were associated with osteoporosis or lipodystrophy. However, covariates associated with an increased risk of osteoporosis were increasing age, lower body mass index (BMI) and hepatitis C coinfection. Covariates associated with an increased risk of lipodystrophy were older age, hypertension, longer antiretroviral duration, and longer exposure to nucleoside reverse transcriptase inhibitors (NRTIs) and integrase strand inhibitors (INSTIs). Conclusion: No association was found between any of the lifestyle factors of interest and osteoporosis or lipodystrophy.